Objective: To perform a systematic review and meta-analysis of subtrochanteric femur fractures treated with an intramedullary nail, augmented with or without cerclage wiring, comparing the risk of reoperation, nonunion, loss of fixation, and implant failure; fracture reduction and time to union. Data Source: A systematic review according to PreferredReporting Items for Systematic Reviews and Meta-Analyses guidelines was performed through MEDLINE, EMBASE, PubMed, Web of Science, and Scopus databases using a combination of controlled vocabulary and keywords on September 30, 2020.Study Selection: All comparative (prospective and retrospective) studies of subtrochanteric fractures managed with intramedullary nail, that compared the addition of cerclage wire to without in patients 16 years of age or older were included. Pathological, atypical bisphosphonate, and segmental fractures were excluded, as were non-English literature.Data Extraction: Data from each study were independently recorded by 2 investigators.Data Synthesis: Agreement was obtained on 18 studies (all retrospective) for final inclusion, with 378 patients receiving cerclage wire and 911 without. A random-effects meta-analysis was used to analyze the pooled aggregate data. Conclusions:There is no statistically significant advantage in using cerclage wire with femoral intramedullary nail when treating subtrochanteric femur fractures regarding risk of reoperation, nonunion, loss of fixation, and implant failure or time to union. An advantage favoring cerclage wire was seen for accuracy of fracture reduction. Cerclage wiring was used more often in cases associated with high-energy trauma. Given the relatively small number of events available to be modelled, a clinical benefit for cerclage wiring may still exist for certain fracture types.

Background:Medial pivot (MP) designs are growing in popularity. They provide increased sagittal plane stability and theoretically replicate some aspects of native joint kinematics, which may improve total knee arthroplasty outcomes.Methods:A systematic review was performed of randomized controlled trials (RCTs) that compared MP designs with cruciate-retaining, posterior-stabilized (PS), ultracongruent, or mobile-bearings in primary total knee arthroplasty, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome measures were all clinical function scores, patient-reported outcome measures, and range of motion. The secondary outcome was complications. Two authors independently selected studies, performed data extraction, and risk-of-bias assessment. Studies at high risk of bias were excluded from meta-analysis. Treatment effects were assessed using random-effects meta-analysis and quantified using pooled mean differences or incidence rate differences as appropriate.Results:Eight RCTs met inclusion criteria. Five compared MP with PS, two with ultracongruent, and one with cruciate-retaining and mobile-bearing. In total, 350 knees were randomized to MP and 375 to conventional bearings. One RCT was excluded from meta-analysis because of high risk of bias. Meta-analysis comparing MP with PS only was possible and found no differences at any time points for any outcome measure, including 2-year follow-up for Oxford Knee Score (MD = 0.35 favoring PS; 95% CI −0.49 to 1.20) and range of motion (MD = 1.58 favoring MP; 95% CI −0.76 to 11.92, P = 0.30) and 12 months for Western Ontario Arthritis Index (MD = 4.42 favoring MP; 95% CI −12.04 to 3.20, P = 0.09).Conclusions:There is no difference in clinical outcomes, with contemporary measurement tools, at any time points, between MP and PS. There are insufficient RCTs comparing MP with other bearings.